Friday, March 4, 2016

3rd Year Chronicles: Surgery

BEEP BEEP BEEP BEEP

The unrelenting wail of my pager cut through the heaviness
of my dreamless sleep. I opened my eyes and fumbled to turn it off before it
woke the person trying to sleep a couple of bunks over from me in the call
room. It was a text page.

Someone is eager to retract...

"Come to CT in the ED."

It was almost 1 am on a Friday night. I was on trauma call
at Loyola at the end of my third of eight weeks on my surgery rotation. For the
first half of the rotation, my days had been spent on the vascular surgery
service at the nearby VA hospital.

The days were long - I usually was there around 4:30 am to
prepare the patient list, round on my post-operative patients, and write my
notes before rounding again with the team around 6 am or so. After rounding,
our usual two or three cases would keep us in the OR from anytime until noon on
a short day to 4 pm or later on a longer one. After a few hours of taking care
of miscellaneous tasks throughout the hospital, seeing consults, attending
lectures, and checking on our patients in the afternoon I was usually able to
finally leave the hospital anywhere from 5 pm on a good day to 8 pm or so on a
longer one.

When I came home, I was pulled between needing to read up
on the next day's cases, trying to get some general studying in for our surgery
shelf exam at the end of the rotation, preparing any presentations that I had
been asked to give, taking care of what felt like a million different
miscellaneous things that needed to be squared away before fourth year and
residency applications began, and – most importantly – spending as much time as
possible with my wife and son. Sleeping was usually on the list in there
somewhere, too.

After a few weeks on that merry-go-round, I was exhausted.
During the days, it was difficult to find time to eat, drink, or use the
bathroom. When I finally got home at the end of the day, I really just wanted
to sit down with my family in front of the electric heater in our living room –
the older house we are renting doesn't stay very warm when it is in the single
digits outside – and just relax with them, chase my son around the house, and
spend time with my wife.

But there was no going home tonight. Fridays were busy days
anyway at the VA. In the mornings, we rounded as usual and then went to several
hours of conference. After taking care of any miscellaneous tasks on the
floors, we then went to clinic. Technically, it was scheduled for three hours.
But since they routinely tried to squeeze in 40-45 patients in that time span,
it was something we all dreaded each week. The clinic was always ridiculously
crazy and fast-paced, and by the time we were getting to the end of the
afternoon – several hours behind schedule at that point – the patients were
almost all (understandably) peeved about having to wait so long.

Of course, that made things even more enjoyable. Once the
patients were all seen, we would breathe a sigh of relief and start writing our
notes – which would usually take up the next couple hours – and finishing up
things on the floors for the day. After that, we finally would go home.

Tonight, though, was different. After finishing clinic, but
before getting a chance to write my notes for that day, I headed over to Loyola
to start my overnight trauma call. After meeting up with my resident for the
night, we spent the next few hours seeing random consults and admissions
throughout the hospital. Finally, around 9 or 10 pm, things started to slow
down a bit. I went to the call room to try get a little bit of studying in, but
that didn’t last long. I quickly fell into a deep, empty sleep. That,
apparently, wasn't how I was going to spend the rest of the night.

After I found my shoes, threw on my white coat, and tried
to quietly fumble my way out of the call room, I headed downstairs to the
emergency department and found the imaging room. A small group was huddled
around the screens displaying images that were just being taken of the patient lying
on the table in the CT machine beyond the glass pane. They weren't very
promising images, either.

The story we initially heard was that a teenager
was found by friends after he had slipped on ice and hit his head. We'll call
him Peter. EMS arrived about 15 minutes later and he was brought to the ED,
where he was intubated and sedated since he had a significantly decreased level
of consciousness and was agitated on arrival.

The images we saw, though, suggested someone wasn't telling
the whole story. This kid had two different skull fractures and bleeding all
throughout the brain. His brain was swelling in response to the injury and
essentially trying to escape through the hole in the bottom of the cranial
vault and his pupils were fixed and dilated – a very bad sign of neurological
injury. Had this been anyone else – anyone other than a young kid - it more
than likely would have been deemed that any significant intervention wouldn't
change the prognosis, which was very poor. Since Peter was younger, though,
they had to at least try. Nevertheless, the odds of him surviving were grim.

After some further imaging, neurosurgery placed an external
ventricular drain – basically something that amounts to a catheter inserted
through a hole they drill in the skull to drain some of the fluid that normally
circulates throughout the brain to reduce intracranial pressures. If the
increased pressures continued, they would kill him.

Normally when the drain is inserted, the clear fluid
normally dribbles out the end of the catheter. In his case, though, the fluid
was spurting out the end of it like water does when you put your finger over
the end of a hose. Not a good sign.

Around this time, the family was starting to trickle in. We
eventually learned from one of Peter's friends that he had actually hopped on
top of the hood of a slow-moving car that the friend was driving. The friend
was startled and quickly hit the brakes, throwing Peter off of the hood of the
car and to the ground, where he hit his head.

Soon after the drain was inserted, the patient went back to
the OR. There, the neurosurgeons essentially lifted up the left half of his
scalp from his skull and then removed the exposed portion of the skull – the
entire left side of his head. The whole time, the brain seemed like it was
trying the escape the room. When they finally cut through the dura mater – a
thick covering over the brain that normally protects and encloses it – it
finally was allowed to swell without compressing itself on the inside of the
skull.

By the time they got to this point, I was around maybe hour
25 or 26 of my shift. I was exhausted. Not only had the preceding week been
incredibly busy and sleep been scarce, but I knew I still had at least a couple
of hours of work ahead of me – before I left, I needed to go back to the VA to
wrap up my notes from the prior day.

All throughout medical school, we had been warned about
various studies demonstrating a decrease in the measured "humanity"
or empathy of students that has been observed from when they start their first
year as compared to when they finish. The steepest drop often happens in third
year. So far, I felt like this hadn't been really been an issue. I've enjoyed
most of my rotations so far, I've enjoyed my patients, and I've had a good time
overall. I've even really enjoyed my surgery rotation. Taking part in patient
care, being a part of the medical team, and learning "real medicine"
has been very satisfying.

Tonight, though, was different. Tonight, as I was standing
near the head of the bed, watching this young kid fight a losing battle for his
life… I realized something.

I didn't care.

That wasn't entirely true. There was a small part of me,
deep down, that was breaking for Peter and his family. We've all done stupid
things before, but now this young man was paying for it with his life. But
there was a bigger part of me, a more immediate and present part, that didn't
feel any of that. A part of me that just wanted to go finish my notes and go to
sleep for the next week.

I could easily explain this away as a bad day on my part. I
could say that I was just exhausted, and that things would be better after a
day off and decent night's sleep. And maybe all that is true. But the fact
remained that I found myself that night experiencing something I never really
thought I would – a distinct, undeniable feeling of indifference for a patient.
Something that I would sometimes see in residents or attendings who were
further down the road and swear to myself that I'd never become like that.

Peter survived the surgery and was transferred to the
pediatric ICU, where he remained for almost a week in critical condition. His
family slept at the hospital, staying at his bedside as much as they could.
Pastoral care and social workers did their best to help the family manage their
feelings and help them with all of the little things that need to be addressed
when a loved one is critically ill. Peter's intracranial pressures actually
slowly began to improve, but he then began to require mechanical ventilation to
breath adequately. His hospital course was complicated by one of his lungs
collapsing, a lung infection, a deadly respiratory distress syndrome that
sometimes occurs after trauma, and eventually progressively worsening blood
pressures.

Finally, late in the afternoon on what would be his last day in the
hospital, Peter's status was continuing to worsen. After one final flurry of a
failed resuscitation attempt, his father decided that it was time. One more
round of drugs was given in a futile attempt to prolong his life until another
family member could arrive, but Peter died around 6:30 pm that evening before
they got to the hospital.

Several weeks later, I'm now nearing the end of my surgical
rotation. After the end of the fourth week, we switched services and I was
assigned to surgical oncology. This has been another busy service with some
very sick patients, not all of whom have survived the surgeries that were meant
to be a last attempt at a cure. Some of those who have survived still don't have
long to live – maybe a couple of years at best.

I'm still tired. That seems to be a defining feature of
this rotation and probably won't go away with the next one. But my experience
that night at Peter's bedside has stuck with me. It taught me how easy it is to
lose the "bright-eyed and bushy tailed" optimism that so many of us
start third year with and gave me a little more understanding for those weary
residents and attendings who, from my relatively rested point of view as a
medical student, were maybe a bit shorter or seemingly uncaring with patients
than I would like to think I would be. But for all I know, perhaps I'd be even
worse if I was in their shoes. I hope not. To you, the reader, perhaps this all
seems a bit silly and blown out of proportion. And perhaps you're not wrong.
For my own part, though, my hope is that this experience serves as a reminder
going forward to continue to reflect on my "spirit" as a medical
professional and ensure that it doesn't get beaten down by the rigors of the
path to come.

The Verdict

So will I go into surgery? Probably not. That being said, I
really did enjoy the rotation. I think I would be happy in a surgical field,
but then I’d be happy in most fields of medicine. There’s definitely an
important distinction to be made between being satisfied with your career and
being satisfied with your life in general – notably, the former doesn’t
necessarily beget the latter.

I really enjoyed a lot of things about this rotation. I
enjoy working with my hands. I enjoyed the (mostly) definitive fixes that we
were able to offer patients most of the time. I would imagine that being the
person who reached inside someone and fixed them is an immensely satisfying
thing.

But.

I also hated the rest of my life during this rotation. Most
everyone that I worked with seemed to not enjoy (or, perhaps more accurately –
not be able to enjoy) their life outside of the hospital. I’m all for working
hard, and there’s a small part of me that would go into surgery just because I
like to do hard things. But most of those who go into surgery seem to have a
rather unique mentality – the training demands that those who would wield the
scalpel not only be willing to work themselves to the bone but enjoy doing so,
and then come back and ask for more. It demands that those who aspire to be a
surgeon give everything that they have to that end. It demands that surgery be
the most important thing in their life, regardless of the cost to everything
else they might value. At least, that’s what it seems to take to be a “good”
surgeon. And while all of that sounds noble and good, it has a not-so-subtle dark
side.

One resident that I worked with has a wife, a two year-old
child, and one on the way – a similar situation to myself. I was trying to pick
his brain about how this all worked during his busy residency. His response
was, “It’s fine. My wife [she worked nights as a nurse] picks our kid up from
daycare on her way to work in the evenings and drops her off at a friend’s
house. I pick her up from there on my way home from work and put her to bed. In
the morning, I’ll take her back to her friend’s house on my way to work, and
then my wife will pick her up from there and drop her off at daycare for the
day. We may not see each other for a couple of days, but that’s fine. It works.”

No. That’s not fine. At least not for me. Being a good
doctor is important to me. It’s an incredible profession that demands a lot of
its trainees, regardless of what field they go into – and rightly so. I’m more
than willing to work hard. But there’s more to life that being the “best doctor
ever” or proving to your colleagues that you can take endless amounts of abuse.
I value my future career, but I also value being a good husband and father, one
who can be present in and participate in my family’s lives. I have interests
outside of medicine that are important to me as well.

There are certainly those who balance a surgical field with
all of the above and do it well. But there are very real costs to such a path
that need to be counted before one enters onto it. Particularly when you are
entering a field where certain residency programs used to actually boast of
divorce rates greater than 100%, you have to understand that you are fighting
the tide when it comes to maintaining a healthy family life during your
training. Sure, residency and fellowships are temporary, but that’s still five,
six, seven years of your life. And most of the attendings that I worked with
didn’t seem to slow down much themselves.

One piece of advice I’ve heard is, if you’re thinking about
going into a field, try and identify someone in that field who is living the life
you hope to live when you get to where they are. If you can’t find that person,
it probably is for a good reason. For me, I was just trying to find someone who
was able to spend enough time with his or her family. I had the opportunity to
work with a pretty large number of attendings, but most of them either 1) had
very young families (i.e. didn’t start a family until after most or all of
their training was done and they were established in their career) 2) were
single 3) saw their families “enough” for them (e.g. “I saw my kid once this
week – that’s enough for me”) or 4) seemed like they were always working and
bemoaning not being able to make it home for planned events or whatever.

Some people get into the OR and feel that they’ve found
their home. That wasn’t my experience. As I said, I certainly enjoyed it. But I
won’t really miss it all that much. And therein lies the important decision
point – if surgery turned out to be “the one thing” in medicine that I truly
enjoyed, then we would consider starting down that path. It would be difficult,
but we would without a doubt come out the other side stronger for it. But the
stuff that doesn’t kill you, while it makes you stronger, also leaves scars.
Those scars can run deep, and at least for me and my family, they aren’t worth
it.

I guess I’m writing all of this because I really had to
think quite a bit about what I was hoping to get out of medicine and life in
general during this rotation. There were a number of times where, after having
the opportunity to do something “cool” or see some incredible anatomy that I
could peer into the future and see myself doing this. But there were also
plenty of times where I missed out on some special moment with my son or some
quality time with my wife because I was at the hospital during all hours of the
day (or night), and when I was at home I was exhausted and not truly there.

As I said, to some degree that’s just part of medical
school and residency in general, and those features are by no means unique to
my surgical rotation – I’ve experienced busyness and fatigue throughout third
year. But the mentality of the field is different – in other rotations, working
long hours or missing out on stuff happening outside the hospital was a
begrudgingly accepted part of training. No one liked it, but it was
acknowledged as being a necessary part of becoming a doctor. During this
rotation, though, that type of stuff was almost worn as a badge of honor. That’s
just not me.

I have a lot of respect for those who go into surgery, and
I hope this post doesn’t dissuade anyone who truly is meant for that field (I
doubt that it would). But for those who are reading this who might already have
a family or are planning on starting one soon, I think it’s certainly worth
taking a step back before plunging into the field and counting the cost. For
some, it may be worth it – and rightly so. The field of surgery is varied and
incredible. For those like me, though, who could have a satisfying career in
many different areas of medicine, it might be worth thinking twice before
committing yourself to that path.

3 comments:

Thank you so much for your posts and sharing your experiences. I'll be an M1 at Loyola this fall, and I'm so glad to have stumbled upon your blog a few months ago.

I appreciate your discussion about the impact that burnout can have on students (especially those in third year), residents, and attendings. We hear and read about burnout and exhaustion in medicine everywhere. I immediately thought of Danielle Ofri's "What Doctors Feel" when I read about your discussion of work-life balance. She talks about the different emotions physicians have in the practice of medicine (i.e. anger, shame, guilt, joy, etc) and includes specific encounters with patients that are both powerful and moving.

Empathy is a recurring theme throughout the book, as well as the expected diminution of it as one progresses through the demands and rigor of the medical career. I appreciate your transparency about your encounter with diminishing empathy during the surgery rotation. I have learned and read a lot about impersonal doctors who are detached and withdrawn, and I too have sworn never to become like that. But the reality is, at one point or another in this career, apathy will inevitably knock on all of our doors. I believe that to combat this, a couple of things we must do is take a step back to self-reflect (as you have beautifully done here) and continually reinforce the essentiality of humanism in medicine.

Thanks again for this post. I share all of your sentiments and thoughts both professionally and personally. I'm very excited to read your future posts (and catch up on the older ones)!

Congrats on your acceptance! Loyola is a great school, in my admittedly biased opinion. They'll teach you how to be a good clinician, but they also value being a good human as well and actually do things to help you remember that along your path through medical school. I remember talks about this stuff and encouragements to reflect in our preclinical years. At the time, I think many of us wrote if off as being a bit silly, but I certainly appreciate now emphasis Loyola places on reflection and personal well-being. These are important "soft" concepts that are just as important to being a good physician as being as to listen to hearts and lungs.

Anyway. I'm rambling, but congrats again and good luck this fall. Feel free to contact me with any questions you might have as you are getting started.

Thank you for sharing your experience, you provide an amazing level of analysis on how a career in medicine needs to be balanced with the things that we hold dear. Your post reminds me of my time as an ER scribe when one of the physician's sons came to shadow a PA. When I asked him why he did not want to be a physician, he told me his father and mother were both doctors, and he did not want his children to have the same experience he had growning up (ie never spending time as a family). I wish you the best with your remaining rotations!